doi:10.1684/epd.2011.0454 , 1 , Veysi Demirbilek 2 Epileptic Disord, Vol. 13, No. 3, September 2011 1 abnormal intestinalnary or faecal motility, incontinence, flushing uri- or ,coughing, pupillary cardio-respiratorythermoregulatory alterations. and changes, Con- ventional seizureimpairment of symptoms, consciousnessmotor as and seizuresfocal in (frequenteyes), the unilateral deviation or secondary form gene- ofralised of the phenomena motor andoccur , headache, as2007). may visual well Inaffected (Panayiotopoulos, children, twoonly seizures during thirds occur sleepin and (66%) the particularly firstsound of hour of clinico-EEG sleep.Panayiotopoulos manifestations, Despite escaped syndrome recognition for many years, has , Aysin Dervent 2 , Irem Hamamcioglu 1 , , benign childhood focal seizures, non- – Panayiotopoulos syndrome is one of the most common [Published with video sequences] et al., 2006). Epileptic Disord 2011; 13 (3): 304-7 Clinical commentary with video sequences Cerrahpasa Faculty of Medicine, DepartmentCerrahpasa of Faculty Neurology of Medicine, Department of Pediatric Psychiatry, Panayiotopoulos syndrome (PS)a is benign, age-relateddisorder focal occurring in early and mid- childhood. Itseizures, is often prolonged, with characterized pre- dominantly by autonomic symptoms, and anand/or EEG multiple thatoften with spike-wave shows occipital shifting foci, (Ferrie predominance In a typicalwith PS presentation, presents acharacterised with child ictal by events sea pale and face,conscious, nau- vomiting, ableunderstand while tophenomena, being others. speak othertriad than Autonomic of and the emesisand (, vomiting) full which retching, about is 74% present in of cases, may include Burak Dogangun Istanbul University, Istanbul, Turkey Received May 2, 2011; Accepted June 26, 2011 A case imitating Panayiotopoulos syndrome Feray Bolukbasi 1 2 ABSTRACT childhood-specific epileptic disorders.symptoms; It the is most characterizedemetic common symptoms by may being cause autonomic misdiagnosis, emesis.disorders for which example However, have with similar the some autonomic organic features. presencethis On syndrome the of has other hand, been since recentlyrecognition well may lead documented, to the overdiagnosis. Here, tendency webe present for a mistaken early case for which Panayiotopoulos could syndrome basedwith on the aid anamnesis, of however, ictal video-EEG monitoring,with the a patient non-epileptic was psychogenic shown seizure. to This present reportful is an evaluation example of in care- disorder. order to avoid over-Key or words: underdiagnosis ofepileptic psychogenic this seizures, benign Panayiotopoulos syndrome, self-induced 304 Correspondence: V. Demirbilek Cerrahpasa Faculty of Medicine, Department of Neurology, Istanbul University, Istanbul, Turkey Case imitating Panayiotopoulos syndrome

for many reasons. Ictal vomiting is rarely considered for an uncle with epilepsy and bipolar disorder. When as a seizure event, however, when associated with he was eight years old, he witnessed the drowning a deteriorating level of consciousness and followed of his uncle. Afterwards, he had stereotypic attacks by , or other acute cerebral which occurred with a frequency of every three to insults are the prevailing diagnoses at the acute stage. four months, for four years. For the last three months, If children with PS are examined after complete reco- they appeared monthly.An attack would start with wak- very, diagnosis of atypical , gastroenteritis, or ing up from sleep, calling out for his mother, repeated new seizure onset is often concluded. Similarly, ictal retching and then vomiting. He would look confused, has only recently been recognized as an talking meaninglessly and using abusive language. The important clinical manifestation of Panayiotopoulos attack would end after a minute or so with a sub- syndrome; ictal syncope may be misdiagnosed as car- sequent headache. At the beginning of his last two diogenic syncope, pseudoseizure, or a more severe attacks, he described a vision of dark geometric figures encephalopathic state (Panayiotopoulos, 2002). coming towards him. Attacks characterised by abnormal autonomic, motor, His neurological examination did not reveal any abnor- sensory and behavioural properties may also be result malities. Routine biochemical testing was within the of emotional and psychological disorders. However, normal range. According to his cranial MRI, the posi- these attacks are not accompanied by abnormal elec- tion of the cerebellar tonsils was 1 cm above the basion trical discharges on EEG and are called “non-epileptic and opisthion (BO) line with a cerebellar ectopic area pschogenic seizures” (NEPS) (Krumholz, 1999; Reuber, of 1 cm diameter. 2008). Because of the attacks during sleep with autonomic Here, we present a case that may suggest PS clini- features, involvement of consciousness and postic- cally, however, the patient had a normal EEG and tal headache, the differential diagnosis included PS. self-induced post-tussive vomiting, as demonstrated However, on video-EEG monitoring, upon arousal, he by video-EEG monitoring. had provoked post-tussive vomiting, his conscious- ness was preserved and the ictal EEG (figures 1, 2) did not show any abnormalities. Case study Psychiatric examination and evaluation A 12-year-old boy with normal psychomotor develop- ment was referred to us with vomiting attacks. His The patient expressed his complaint as follows: “I family history did not show any significance except wake up from my sleep at night screaming Mom! and

Figure 1. Ictal EEG 1 showing no abnormalities.

Epileptic Disord, Vol. 13, No. 3, September 2011 305 F. Bolukbasi, et al.

Figure 2. Ictal EEG 2 showing no abnormalities.

I feel like something bad is going to happen to my to the cessation of symptomatic behaviour. Accord- family if I don’t throw up. I look at the mirror, per- ing to the information gained by telephone later, he form some gestures towards myself, and then I throw was free of nocturnal enuresis for six months and of up”. night-time vomiting episodes for one year at the last The family reported that this symptom started after our control. patient had witnessed his uncle drowning due to an His psychiatric profile was interpreted as covering epileptic attack, at the age of eight. intense guilt feelings and an inclination to see himself The patient’s developmental history was unremark- as the cause of unfavourable family events. His puerile able except for primary nocturnal enuresis up to the personality structure had disabled him from process- age of 11.5 years. Psychiatric history revealed somatic ing aggression in an appropriate manner for his age; complaints, such as knee and headaches. Family his- causing aggression to either surface uncontrollably, or tory revealed treatment for depression for the mother converge internally and lead to feelings of guilt. It was five years ago for a period of six months, substance concluded that the death of his uncle prevented the abuse for the father and bipolar disorder for the patient from dealing with negativity towards a sub- deceased uncle with epilepsy. ject and the guilty feelings were surfaced by a scene During the psychiatric examination, the patient was very similar to that of the drowning of his uncle, anxious, but cooperative. His mental associations were accompanied by feelings of harm towards his loved partially accelerated and thought process involved ones. preoccupations with unfavourable situations concern- ing family members. Mental capacity was appropriate for his age, and no other signs of psychopathology Discussion were determined except for excessive somatic anxiety. Following the therapy sessions, during which the Vomiting is a common manifestation of both organic patient’s feelings of guilt and the unpleasant memory and functional disorders, therefore the differential about his uncle were addressed, a substantial improve- diagnosis of cases with vomiting, based purely on ment became evident. After a follow-up period of anamnesis, can be challenging. Concerning vomiting nine months, the family cancelled the treatment due as the main symptom, PS should also be included in the

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list of differential diagnosis. PS is a common, benign, Legend for video sequence early onset childhood-specific autonomic epileptic disorder. Although the prevalence is reported to be The patient hyperventilates, coughs repetitively and around 13% in three- to six-year-old children, with then performs seemingly self-induced vomiting. one or more non-febrile seizures, or 6% in the age group of 1-15 year olds in the original cohort of Key words for video research Panayiotopoulos (1988), the actual prevalence may on www.epilepticdisorders.com be higher (Panayiotopoulos, 2002). Current diagnosis Etiology: behavioural and personality disorders Phenomenology: nonepileptic paroxysmal event; with characteristic clinical manifestations and inter- autonomic seizure; vomiting (ictal); ictal EEG findings is now easier, based on recent Localization:– informative reports (Panayiotopoulos, 2008). How- Syndrome: non epileptic paroxysmal disorder ever, a single routine EEG may be normal in 10% of patients and EEGs during wakefulness may be con- sistently normal in a small number of children prior References to a diagnostic sleep recording. Sometimes, sleep EEG may also need to be repeated (Michael et al., Asano E, Akiyama T. What is the point of specifying 2010). Panayiotopoulos syndrome from a practical point of view? The exaggerated tendency for recognition of emetic Brain & Development 2010; 32: 2-3. and other autonomic manifestations as seizure events Ferrie C, Caraballo R, Covanis A, et al. Panayiotopou- may bring about the problem of overdiagnosis of los syndrome: a consensus view. Dev Med Child Neurol this disorder. The features suggesting the possibi- 2006; 48: 236-40. lity of PS in our case were the occurrence of attacks Krumholz A. Nonepileptic seizures: diagnosis and manage- during sleep, the patient’s unresponsiveness (which ment. Neurology 1999; 53: 76-83. could be interpreted as involvement of conscious- ness), vomiting, and a subsequent headache. On the Michael M, Tsatsou K, Ferrie C. Panayiotopoulos syndrome: An important childhood autonomic epilepsy to be diffe- other hand, based on his video-EEG recording upon rentiated from occipital epilepsy and acute non-epileptic awakening, he coughed, hyperventilated, retched and disorders. Brain & Development 2010; 32: 4-9. then finally presented post-tussive vomiting, although Panayiotopoulos CP. Vomiting as an ictal manifestation of EEG showed a normal trace, as it did during the whole epileptic seizures and syndromes. J Neurol Neurosurg Psy- course of the study. chiatry 1988; 51: 1448-51. Our case is an important example of the necessity for Panayiotopoulos CP. Panayiotopoulos syndrome: a common careful interpretation of clinical data and EEG find- and benign childhood epileptic syndrome. London: John ings in cases presenting with autonomic findings, Libbey, 2002. such as vomiting, to prevent over- or underdiagnosis of this common, benign, childhood-specific epileptic Panayiotopoulos CP. Benign childhood focal seizures and related epileptic syndromes. In: Panayiotopoulos CP. A cini- disorder (PS), of which the location of the symp- cal guide to epileptic syndromes and their treatment. London: tomatogenic zone is not known (Asano and Akiyama, Springer-Verlag, 2007: 293-302. 2010).  Panayiotopoulos CP. Benign childhood focal : assessment of established and newly recognized syndromes. Disclosure. Brain 2008; 131: 2264-86. None of the authors has any conflict of interest or financial Reuber M. Psychogenic nonepileptic seizures: answers and support to disclose. questions. Epilepsy Behav 2008; 12: 622-35.

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